Billing and payment of commercial and Medicaid health plan adult vaccination claims in Michigan since the Affordable Care Act.
Billing and payment of commercial and Medicaid health plan adult vaccination claims in Michigan since the Affordable Care Act.
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自《平价医疗法案》颁布以来，密歇根州商业和医疗补助健康计划成人疫苗接种索赔的计费和支付。
DOI：
10.1016/j.vaccine.2019.09.042
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发表时间：
2019
期刊：
影响因子：
5.5
通讯作者：
Hutton,DavidW
中科院分区：
文献类型：
--
作者：
Goodman,RobertM;Bridges,CarolynB;Kim,David;Pike,Jamison;Rose,Angela;Prosser,LisaA;Hutton,DavidW
背景提供者对保险不支付疫苗费用的担忧是提供成人免疫接种的常见障碍。我们检查了与两个管理式医疗人群相关的当前成人疫苗接种账单和付款情况，以确定不支付免疫保险索赔的原因。方法我们评估了非营利性健康维护组织密歇根州 Blue Care Network 和医疗补助管理式医疗计划密歇根州 Blue Cross Complete 2014 年至 2015 年的管理数据，以确定患者护理环境、保险计划和疫苗类型中成人疫苗接种索赔不支付的比率和原因。我们将商业和医疗补助支付率与医疗保险支付率进行了比较，并检查了患者费用分摊。结果药房提交的成人疫苗剂量索赔几乎总是得到支付（商业 98.5%；医疗补助 100%）。由于医生办公室在医疗（非药房）疫苗接种服务中占绝大多数（79% 商业；69% 医疗补助），因此我们将商业和医疗补助医疗索赔的进一步分析限制在医生办公室环境中。在医生办公室环境中，支付率很高，商业支付率 (97.9%) 高于医疗补助率 (91.6%)。不付款的原因多种多样，但通常与成人疫苗建议的复杂性（患者诊断与建议不符）或保险范围（复杂的合同、多个保险付款人）有关。疫苗管理服务通常也是有偿的。商业健康计划支付的疫苗剂量和疫苗接种费用均高于医疗保险支付；与 Medicare 相比，Medicaid 为疫苗剂量支付的费用较高，但疫苗接种费用却较低。患者的疫苗接种费用通常非常低（商业）或没有（医疗补助）分摊。结论 成人疫苗剂量索赔通常得到支付。医疗补助的不付款率普遍高于商业保险。
BackgroundProvider concern regarding insurance non-payment for vaccines is a common barrier to provision of adult immunizations. We examined current adult vaccination billing and payment associated with two managed care populations to identify reasons for non-payment of immunization insurance claims.MethodsWe assessed administrative data from 2014 to 2015 from Blue Care Network of Michigan, a nonprofit health maintenance organization, and Blue Cross Complete of Michigan, a Medicaid managed care plan, to determine rates of and reasons for non-payment of adult vaccination claims across patient-care settings, insurance plans, and vaccine types. We compared commercial and Medicaid payment rates to Medicare payment rates and examined patient cost sharing.ResultsPharmacy-submitted claims for adult vaccine doses were almost always paid (commercial 98.5%; Medicaid 100%). As the physician office accounted for the clear majority (79% commercial; 69% Medicaid) of medical (non-pharmacy) vaccination services, we limited further analyses of both commercial and Medicaid medical claims to the physician office setting. In the physician office setting, rates of payment were high with commercial rates of payment (97.9%) greater than Medicaid rates (91.6%). Reasons for non-payment varied, but generally related to the complexity of adult vaccine recommendations (patient diagnosis does not match recommendations) or insurance coverage (complex contracts, multiple insurance payers). Vaccine administration services were also generally paid. Commercial health plan payments were greater for both vaccine dose and vaccine administration than Medicare payments; Medicaid paid a higher amount for the vaccine dose, but less for vaccine administration than Medicare. Patients generally had very low (commercial) or no (Medicaid) cost-sharing for vaccination.ConclusionsAdult vaccine dose claims were usually paid. Medicaid generally had higher rates of non-payment than commercial insurance.